Change in tongue pressure and the related factors after esophagectomy: a short-term, longitudinal study

Swallowing Safety after Remote sub-total Esophagectomy: How Important is Tongue Pressure?

The factors related to oropharyngeal dysphagia after remote esophagectomy (greater than five months) remain unclear. This study aimed to assess patient perception of dysphagia, maximum anterior isometric pressure (MAIP), maximum posterior isometric pressure (MPIP), lingual swallowing pressure (LSP) and radiographic physiological components of the oral and pharyngeal phases of swallowing in patients who are post remote sub-total esophagectomy (SE). Patient perception of dysphagia was assessed using the Eating Assessment Tool (EAT-10). MAIP, MPIP, and LSP were measured using the Iowa Oral Performance Instrument. Videofluoroscopy was used to assess the physiologic components of swallowing with the Modified Barium Swallow Impairment Profile (MBSImP) and the Penetration-Aspiration Scale (PAS). Ten patients were included in the study (53.2% male; mean age 54.5 ± 18.0). The mean postoperative time was 30 months (range, 5.0-72 months). Seven patients had elevated EAT-10 scores (> 3). All patients demonstrated impaired oropharyngeal swallowing on at least three MBSImP components (range 3-12) and two patients aspirated (PAS 8). There was a significant difference in MAIP values when comparing patients with normal versus impaired laryngeal elevation and epiglottic movement (p < 0.001). MPIP values were significantly different in patients with normal versus impaired epiglottic movement as well as normal versus elevated PAS scores (p < 0.001). Decreased lingual pressure and physiological changes in swallowing coexist after SE. Our results indicate that the decrease in tongue strength may be one of the factors related to unsafe swallow. The assessment of lingual pressure provides diagnostic value and should be incorporated as part of a comprehensive assessment in this population.

Progress on aspiration assessment methods for patients after esophageal cancer surgery in early: A review

Esophageal cancer is a relatively common malignant tumor of the digestive tract. Patients with esophageal cancer show a high incidence of aspiration after surgery, which has a serious impact on their prognosis and rehabilitation. Nevertheless, while existing and past endeavors have concentrated on enhancing the diagnostic and therapeutic strategies for esophageal cancer, the necessity of preventing pneumonia caused by postoperative aspiration remains to be adequately addressed. We compiled the presently published literature and offer the latest developments on the causes of postoperative aspiration in patients with esophageal cancer, screening methods, and swallowing assessment tools. Relevant published papers were collected through a search of the China national knowledge infrastructure, Ovid EMBASE, Web of Science, Cochrane, and PubMed databases. There are various methods for assessing swallowing function after surgery for esophageal cancer. Clinically, it is necessary to select appropriate assessment tools for the swallowing function. Research indicates that the application of risk prediction models can better assess aspiration in patients after esophageal cancer surgery, bridge gaps in qualitative analysis, and alter the clinical outcomes of patients. Predictive models for dysphagia screening in patients after esophagectomy have significant clinical advantages and exhibit good clinical applicability.

Perioperative gum-chewing training prevents a decrease in tongue pressure after esophagectomy in thoracic esophageal cancer patients: a nonrandomized trial

Tongue pressure (TP) decreases significantly after esophagectomy in esophageal cancer patients (ECPs). Meanwhile, 2 weeks of gum-chewing training (GCT) significantly increased TP in healthy university students. We examined whether perioperative GCT would decrease the proportion of patients exhibiting a decline in TP at 2 weeks postoperatively, and prevent postoperative complications, in thoracic ECPs (TECPs). This was a single-center interventional study, and nonrandomized study with a historical control group (HCG). TECPs who underwent first-stage radical esophagectomy were recruited. Thirty-two patients of 40 in the gum-chewing group (GCG) were completed perioperative GCT in 3 times daily. Propensity score matching was performed with covariates related to TP including preoperative age, sex, body mass index, and the repetitive saliva swallowing test result, and yielded a matched cohort of 25 case pairs. Eleven GCG patients [44.0%] exhibited significantly lower TP at 2 weeks postoperatively than before esophagectomy was significantly fewer than that of 19 patients [76.0%] in the HCG. The median number of fever days (> 38 °C) in the 2 weeks after esophagectomy in the GCG was significantly fewer than those in the HCG. Perioperative GCT may prevent postoperative TP decline and postoperative dysphagia-related complications after esophagectomy.

Post-extubation Dysphagia-Early Detection by Serial Tongue Pressure Measurements: Is it Practical?

How to cite this article: Paul S, Pande RK. Post-extubation Dysphagia-Early Detection by Serial Tongue Pressure Measurements: Is it Practical? Indian J Crit Care Med 2022;26(12):1233-1234.

Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery

Background

There is no objective quantitative parameter for dysphagia, and the relationship between changes in maximum tongue pressure values and dysphagia is unknown. This study aimed to determine whether there is a difference in the change in maximal tongue pressure after extubating patients who were ventilated after cardiovascular surgery, with or without dysphagia.

Materials and methods

Adult patients who underwent mechanical ventilation via endotracheal intubation following cardiovascular surgery were included. Tongue pressure was measured before cardiovascular surgery and at 6 hours; 3 and 7 days after extubation. Dysphagia was confirmed by the functional oral intake scale (FOIS) on day 7 after extubation; an FOIS level above or equal to 6 was considered "dysphagia-negative."

Results

Of 68 patients, 15 (22.1%) were in the dysphagia-positive group, which significantly showed a history of diabetes mellitus, prolonged mechanical ventilation, and postextubation hospitalization. Additionally, the postoperative C-reactive protein level was significantly higher in the dysphagia-positive group than in the dysphagia-negative group. Maximum tongue pressure was significantly lower in the dysphagia-positive group at 3 and 7 days postextubation. Using a cutoff value of 27.6 kPa in a receiver operating characteristic (ROC) curve for maximum tongue pressure at 3 days after extubation, the area under the curve (AUC) was 0.82, sensitivity was 84.9%, and specificity was 84.2%.

Conclusion

Tongue pressure at 3 days after extubation is significantly lower in patients with dysphagia after cardiovascular surgery than in patients without dysphagia. If the maximum tongue pressure value is below 27.6 kPa on the third day following extubation, oral intake should be performed with caution.

How to cite this article

Yamada T, Ochiai R, Kotake Y. Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery. Indian J Crit Care Med 2022;26(12):1253-1258.

Clinical significance of sarcopenic dysphagia for patients with esophageal cancer undergoing esophagectomy: A review

The relationships among esophagectomy for esophageal cancer, dysphagia, and sarcopenia are still unclear. We considered appropriate interventions for patients with resectable esophageal cancer for the purpose of reducing postoperative dysphagia and aspiration pneumonia. Dysphagia in patients with esophageal cancer is caused by patient characteristics, such as pathophysiology and age, or complications after esophagectomy. Recently, sarcopenic dysphagia, defined as dysphagia associated with whole-body sarcopenia, has attracted attention in various fields, and a large proportion of patients with esophageal cancer are expected to have sarcopenic dysphagia. Our systematic review and meta-analysis suggested that preoperative sarcopenia in patients with esophageal cancer is related to pulmonary complications after esophagectomy, and some reports also suggested that sarcopenia in swallowing-related muscles, such as the geniohyoid muscle and tongue, might be associated with postoperative pneumonia or dysphagia after esophagectomy. However, clinical studies on sarcopenic dysphagia in patients with esophageal cancer have been limited. To prevent sarcopenic dysphagia after esophagectomy, perioperative interventions involving not only swallowing rehabilitation, but also physical exercise and nutritional support are important. Moreover, several reports have suggested that the chin-down maneuver might be effective for preventing aspiration after an esophagectomy. To inhibit the progression of sarcopenic dysphagia after esophagectomy, evaluations and interventions by multidisciplinary staff are likely to be necessary.

Handgrip strength predicts early postoperative dysphagia after thoracoscopic-laparoscopic esophagectomy in male patients with esophageal cancer

BACKGROUND

Dysphagia after esophagectomy, especially in the early postoperative period, remains a severe complication. The association between sarcopenia and dysphagia has received attention in geriatric non-cancer populations. This study aimed to determine the associations between sarcopenia parameters and early postoperative dysphagia after esophagectomy.

METHODS

This retrospective observational study included 201 consecutive male patients undergoing thoracoscopic-laparoscopic esophagectomy (TLE) for esophageal cancer between October 2018 and December 2020. We used three sarcopenia parameters: handgrip strength (HGS), skeletal muscle index, and gait speed. Postoperative swallowing function was assessed by videofluoroscopy using the penetration-aspiration scale (PAS; range 1-8). Logistic regression analyses were used to predict factors associated with postoperative aspiration (PAS 6-8). Furthermore, we compared values in patients with symptomatic aspiration (PAS 6-7) and with silent aspiration (PAS 8).

RESULTS

Aspiration occurred in 38 of 201 patients (18.9%). On multivariate analysis, significant predictors of aspiration included age [odds ratio (OR) 1.11; 95% confidence interval (CI) 1.05-1.17; p < 0.001], low HGS (OR 3.05; 95% CI 1.06-8.78; p = 0.039), upper third esophageal cancer (OR 2.79; 95% CI 1.03-7.54; p = 0.044) and recurrent laryngeal nerve palsy (OR 2.98; 95% CI 1.26-7.06; p = 0.013). Furthermore, among patients with aspiration (PAS 6-8), low HGS was significantly associated with silent aspiration (OR 6.43; 95% CI 1.06-39.00; p = 0.043).

CONCLUSIONS

Low HGS was significantly associated with early postoperative aspiration and impairment of airway protective reflexes after TLE.

Prevalence, nature and trajectory of dysphagia postoesophageal cancer surgery: a prospective longitudinal study protocol

INTRODUCTION

Dysphagia is a common problem following oesophagectomy, and is associated with aspiration pneumonia, malnutrition, weight loss, prolonged enteral feeding tube dependence, in addition to an extended in-hospital stay and compromised quality of life (QOL). To date, the prevalence, nature and trajectory of post-oesophagectomy dysphagia has not been systematically studied in a prospective longitudinal design. The study aims (1) to evaluate the prevalence, nature and trajectory of dysphagia for participants undergoing an oesophagectomy as part of curative treatment, (2) to determine the risk factors for, and post-operative complications of dysphagia in this population and (3) to examine the impact of oropharyngeal dysphagia on health-related QOL across time points.

METHODS AND ANALYSIS

A videofluoroscopy will be completed and analysed on both post-operative day (POD) 4 or 5 and at 6-months post-surgery. Other swallow evaluations will be completed preoperatively, POD 4 or 5, 1-month and 6-month time points will include a swallowing screening test, tongue pressure measurement, cough reflex testing and an oral hygiene evaluation. Nutritional measurements will include the Functional Oral Intake Scale to measure feeding tube reliance, Malnutrition Screening Tool and the Strength, Assistance With Walking, Rise From a Chair, Climb Stairs and Falls questionnaire. The Reflux Symptom Index will be administered to investigate aerodigestive symptoms commonly experienced by adults post-oesophagectomy. Swallowing-related QOL outcome measures will be determined using the European Organisation for Research and Treatment of Cancer QLQ-18, MD Anderson Dysphagia Inventory and the Swallowing Quality of Life Questionnaire.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Tallaght University Hospital/St. James' Hospital Research Ethics Committee (JREC), Dublin, Ireland (Ref. No. 2021-Jul-310). The study results will be published in peer-reviewed journals and presented at national and international scientific conferences.

Exercise-based dysphagia rehabilitation for adults with oesophageal cancer: a systematic review

BACKGROUND

Dysphagia is prevalent in oesophageal cancer with significant clinical and psychosocial complications. The purpose of this study was i) to examine the impact of exercise-based dysphagia rehabilitation on clinical and quality of life outcomes in this population and ii) to identify key rehabilitation components that may inform future research in this area.

METHODS

Randomised control trials (RCT), non-RCTs, cohort studies and case series were included. 10 databases (CINAHL Complete, MEDLINE, EMBASE, Web of Science, CENTRAL, and ProQuest Dissertations and Theses, OpenGrey, PROSPERO, RIAN and SpeechBITE), 3 clinical trial registries, and relevant conference abstracts were searched in November 2020. Two independent authors assessed articles for eligibility before completing data extraction, quality assessment using ROBINS-I and Downs and Black Checklist, followed by descriptive data analysis. The primary outcomes included oral intake, respiratory status and quality of life. All comparable outcomes were combined and discussed throughout the manuscript as primary and secondary outcomes.

RESULTS

Three single centre non-randomised control studies involving 311 participants were included. A meta-analysis could not be completed due to study heterogeneity. SLT-led post-operative dysphagia intervention led to significantly earlier start to oral intake and reduced length of post-operative hospital stay. No studies found a reduction in aspiration pneumonia rates, and no studies included patient reported or quality of life outcomes. Of the reported secondary outcomes, swallow prehabilitation resulted in significantly improved swallow efficiency following oesophageal surgery compared to the control group, and rehabilitation following surgery resulted in significantly reduced vallecular and pyriform sinus residue. The three studies were found to have 'serious' to 'critical' risk of bias.

CONCLUSIONS

This systematic review highlights a low-volume of low-quality evidence to support exercise-based dysphagia rehabilitation in adults undergoing surgery for oesophageal cancer. As dysphagia is a common symptom impacting quality of life throughout survivorship, findings will guide future research to determine if swallowing rehabilitation should be included in enhanced recovery after surgery (ERAS) programmes. This review is limited by the inclusion of non-randomised control trials and the reliance on Japanese interpretation which may have resulted in bias. The reviewed studies were all of weak design with limited data reported.